Reflections Questionnaire

Name:
 

Date:
 

Your Goals:
What are the three biggest changes you want to make in your life in the next 6 months?

 






What are the three biggest changes you want to make in your life over the next 3 years?

 






Your History:
What would you say have been your 3 greatest accomplishments to date?

 






What is the hardest thing in your life that you have had to overcome?



Who are or have been your major role models?



Have you worked with a coach before or a similar one-on-one adult relationship (e.g. tennis coach, piano teacher, and therapist)? If yes, what worked well for you and what did not work in the relationship(s)?



What major transitions have you had in the past two years? Entering or approaching a new decade, a new relationship, a new job, a new role, a new residence, etc.?



Personal Shift:
Coaching helps you shift your perspective and "where you come from in life" to one that really empowers you and lets you accomplish with ease. What kind of shift do you want now? List shifts you would like to make in the following areas of your life.

Family/home life:
 
Financial situation:
 
Career or Business life:
 
Personal Character:
 
Relationships:
 
Leisure time:
 
Self-care:
 
Learning:
 
Other:
 
Your Life:
Who are the key people in your life and what do they provide for you?



Is your life one of your choosing? If not, which parts are being chosen for you?



What is your favorite part of your typical day?



What is your least favorite part of your typical day?



Looking at the past six months of your life, do you like the direction your life is moving in? Yes/No



On a scale of 1 to 10, 10 high, rate the amount of stress in your life right now. What are your primary stressors?



List five things that you are tolerating or putting up with in your life at present. (examples: information you can't find, clutter, rude friends, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipments, old appliances, etc.).













List five things that you are tolerating or putting up with in your life at present. (examples: information you can't find, clutter, rude friends, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipments, old appliances, etc.).













List five things that you are tolerating or putting up with in your life at present. (examples: information you can't find, clutter, rude friends, poor lighting, tight shoes, dented car, job dissatisfaction, dead plants, broken equipments, old appliances, etc.).













What motivates you?



What are you learning/accepting about yourself at present?



Coaching You:
What would you like me to do if you get behind on your goals?



What types of approaches discourage you or take away motivation?



How will you know when you are receiving value (i.e. your money's worth) from the coaching process?



What else do you want your coach to know?






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